• Enrollment Consent Form (FFM or SBM Marketplaces)

  • I, ________________________________ [name of primary household contact], give my permission to ________________________________ [name of the person or entity who has the consumer's consent] ("Agent") to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace or State Based Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

    • Searching for an existing Marketplace application
    • Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums
    • Providing ongoing account maintenance and enrollment assistance, as necessary
    • Responding to inquiries from the Marketplace regarding my application
  • I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
    • I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.
  • I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.
  • Last updated: December 2023
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  • Privacy Policy
  • Consent may be revoked or modified at any time by emailing vinnytheinsuranceguy@protonmail.com. HealthCare.gov requires documented consent before account, application, enrollment, or financial-assistance work, and state-based Marketplaces may require their own authorization, account-association, or consent process.
  • Please do not enter health information, Social Security numbers, Medicare numbers, payment information, or other sensitive identifiers unless the Marketplace specifically requires the information through an authorized secure workflow.

  • Primary Writing Agent

  • Agency or Assistor

  • Format: (000) 000-0000.

  • Primary applicant

  • Format: (000) 000-0000.
  • Initial consent does not replace the separate application review required immediately before submission. Choose Yes only after the completed Marketplace eligibility application or update has been reviewed with you.

    If this section is left blank, the submission records initial consent only and does not create a final application-review confirmation.
  • Would you like to complete the final-review confirmation?

  • Marketplace Application Review Confirmation

  • Review Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this a new application or an update?
  • I reviewed the eligibility information and end-of-application attestations, and confirm the information is accurate to the best of my knowledge.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last updated: December 2023
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